End of 4th Year

Clinical OSCE
A/L 2001 Batch

Dinusha Liyanapatabendi

Q7
1. Identify A-G
2. Write the corresponding letters in
order of most effective method to
least effective method

1. Identify A-G
2. Write the corresponding letters in order of most
effective method to least effective method
D

 A Female condom
B Levonorgestrel releasing intra uterine contraceptive device (Mirena)
C Copper T-380 A intrauterine contraceptive device
D - Depot medroxy progesterone acetate injectable suspension
E Norplant subdermal contraceptive implant system
F Combined oral contraceptive pill
G- Male condoms
E>B>F=D>C>G>A

% of women experiencing an
unintended pregnancy within the
first year of use
Method

Typical use1

Perfect use2

No method4

85

85

Withdrawal

27

Periodic abstinence
Calendar
Ovulation method
Sympto-thermal6
Post-ovulation

25
9
3
2
1

Condom - Female

21

Condom - Male

15

0.3

0.3

0.8

0.6

Mirena (LNG IUS)

0.1

0.1

LNG implants (Norplant)

0.05

0.05

0.5

0.5

0.15

0.10

Combined pill and minipill

DMPA (Depo-Provera)
IUD (copper T)

Female sterilization
Male sterilization

3
3

Emergency contraceptive pills: Treatment initiated within 72 hours after unprotected

intercourse reduces the risk of pregnancy by at least 75%.

A) 21 yrs old unmarried girl presents to your clinic after having

unprotected sex last night. What method/s that you can use in
this patient as post-coital contraceptive method/s.
B) A 35 yrs old healthy woman with two children aged 3 & 5 yrs
requests an emergency contraceptive after unplanned coitus 4 days
ago. Name a method that you would offer to this woman.
1
3

A.
1 Postinor2
take one tab immediately and the second tablet 12 hrs later
2 Combined oral contraceptive pill
Take 4 tablets immediately and repeat the same dose 12 hrs
later
B.
Copper T 380-A intrauterine contraceptive device
A copper-releasing IUD (Cu-IUD) can be used within 5 days
of unprotected intercourse as an emergency contraceptive.
However, when the time of ovulation can be estimated, the
Cu-IUD can be inserted beyond 5 days after intercourse, if
necessary, as long as the insertion does not occur more than
5 days after ovulation.

Q11
1. How long can it be used
2. List 2 advices you would
give after inserting this to
a patient
3. What should you do if a
woman gets pregnant
after placing it

1.
2.

10 years (6-8)

Expect some bleeding PV for a few days

Check for the presence of the threads (Specially during
menstruation period)
First 3-4 menstrual periods may be heavier than normal
Take paracetamol tablets if she develops lower abdominal pain.
Follow up In one month and thereafter annually
Prompt medical advice should be taken if
- the threads are not felt
- delayed menstrual period (Pregnancy?)
- Severe abdominal pain Prolonged or excessive bleeding

3.

Remove the IUCD

Timing of insertion
1st seven days of the cycle (Ideal during menstruation)

Removal of IUD
pregnancy
Perforation
Acute PID
Menopause one year after last period

Absolute contraindications
Pregnancy
Acute/Chronic PID
Abnormal uterine bleeding
Suspected/confirmed genital tract malignancy

What you should ask in the Hx:

LRMP to rule out possibility of pregnancy
Mucopurulent vaginal discharge - ? PID

Q7

1. Name above items and write one non-contraceptive benefit

of each above given methods
2. 30 yrs old female who is on OCP has forgotten to take her
last two pills. what advise would you give her?

1)
A - Levonorgestrel

releasing intra uterine contraceptive device (Mirena)

B Male condom
C Combined oral contraceptive pills
2)
A-

Improves menorrhagia
Decrease dysmenorrhoea and pelvic pain in patients with endometriosis

B- Protection against STD

Protection from carcinoma of the Cx
C- Relief of menstrual problems
Regularizes previously irregular cycles
Decrease number of days of bleeding and amount
Improves iron deficiency anaemia
Relieves and reduces premenstrual tension
Protection against ovarian and endometrial cancers
Decreases incidence of benign breast cysts and fibroadenoma
Prevent ectopic pregnancy

Missed pills
Sri Lanka Family Planning Association Guidelines
Missed one tablet
Take the missed pill as soon as you remember &
take the scheduled pill at the usual time
Missed consecutive two pills on two days
Take two pills on the third day and two on the
fourth day. From next day onwards take one pill
daily.
Till you get your next menstrual period use
condoms as a backup method OR abstain from sex.

Missed Pill
WHO Guidelines

1. What is the
advice you would
give to the
patient when
prescribing this
2. List 3 Common
side effects

Advice

Postinor contains two tabs. Treatment necessitate to take 2 tabs

Reliable (75%) post coital contraceptive method if it takes <72 hrs after
unprotected sex

1st tab should be taken immediately. 2 nd tab should be taken 12hrs after the
1st dose

If vomiting occurs within 2hrs of intake take another tab.

Can cause irregularity to your next menstrual period

Not a method of abortion

No adverse effects to an already existing pregnancy

Adverse effects Nausia, Lower abd pain, breast tenderness, Vomiting

Consult a physician if you missed your next period

Advise her about proper use of suitable contraceptive method

Q9
Mother giving breast milk to child,
looking far away
1. List 2 correct techniques when
breast feeding
2. List 2 maternal complications due to
incorrect technique of breast
feeding

 Correct technique:

a) Good exposure of both mother and baby.

b) Posture- Mother sitting comfortably. The baby is
held with his head ,neck and body in one line
supported by the mothers forearm.
c) Good attachment- The areola covered by babys
mouth with the lower lip everted and cheeks should
be puffed out.
d) Eye contact to be maintained.
e) Each feed to be around 20 minutes.

Maternal complications:

a) Cracked nipples
b) Breast abcess

Q 14
How do you prepare a patient for
LSCS
What are the complications of LSCS

Consent

Co-ordinative part- inform aneasthetist, PHO and theatre.

Keep fasting

Investigations- Grp & DT( Reserve 1 unit)

Pre-medication- Metachlopromide 10mg oral, Famotidine 20mg oral

Emergency- O2, IV Ranitidine 50mg, IV Metachlopromide 10mg, Na

Citrate 0.3M 30ml. Mother in left lateral position.

Send Urinary cather, IV antibiotics ( Metronidazole 500 mg,

Cefuroxime 750 mg ( 1 vial each) to theatre.)

Complications of LSCS
Anaesthetic Aspiration ( Mendelsons
synd)
Immediate- PPH, shock, damage to bladder,
ureters or colon
Early- Sepsis, Wound complications
(Haematoma, dehiscence)
Late- risk of scar rupture in future
pregnancies, incisional hernia, intestinal
obstruction due to adhesions

Q6
Give 4 risk factors from this antenatal record (Two slides)
Mrs. A

PAGE 1

Orange
+++

Short stature
Previous death in-utero
Previous miscarriages
Blood pressure of 160/110
Proteinuria
Grand multi para

Q8

Tick the items used in manual removal of placenta

1

Plasters

14G foley catheter

14G IV cannula

Vacuum cup

A pair of gloves

Cuscos speculum

IV drip set

Vulsellum

IV metronidazole

10

Betadine

Plasters

14G foley catheter

14G IV cannula

Vacuum cup

A pair of gloves

Cuscos speculum

IV drip set

Vulsellum

IV metronidazole

10

Betadine

Q4

94/95 batch

1. Identify/name
the instrument
2. Write 2 uses

1.

Cuscos bivalve self retaining vaginal

speculum

2.
In obtaining a Pap smear
In obtaining a high vaginal swab
To visualize the cervix & vaginal wall in
pelvic examination

Q18
1. What
do you
see
2. Write 2
causes

1. Secondary arrest
2. CPD
OP position
Inadequate uterine contractions
Mx:
CPD Em LSCS
OP position
Inadequate uterine contractions

Exclude obstruction
Increase oxytocin infusion rate
Observe and if no progression
Em LSCS

Q19 Write a clinical condition where each

of these drugs are used

Hydralazine

Oxytocin
Augmentation of labour.
Active Mx of 3rd stage labour & control PPH.
Following evacuation of uterus.
Mg sulphate
As eclampsia prophylaxis.
Hydralazine
In Pre-eclampsia and eclampsia.
Ergometrine
Prophylaxis against excess heamorrhage foll. delivery
Therapeutic- In PPH: atonic uterine bleeding.
In atonic uterine bleeding foll. Miscarriage, expulsion of H.
mole.

 Counsel this 30 yrs old patient who is

diagnosed to have an incomplete
miscarriage

 Introduce yourself, put the patient at ease

Explain what has happened ( Most miscarriages are
due to fetal anomalies, there is nothing that she
could have done to prevent the miscarriage )
The need to undergo surgery ( Evacuation of
retained products under GA)
Preparation for the next pregnancy wait at least 3
months, during this period take folic acid
Early antenatal clinic booking and regular follow up.
Ask whether patient has any questions to ask

 Ask 5 leading questions to determine

the severity of this patients
condition who has a blood pressure of
160/100 mmHg

 Frontal Headache- unrelieved by simple

analgesia.
Visual disturbance- flashing lights and
spots
Epigastric pain
Nausea/ Vomiting
Swelling
Malaise

Mr. A

Write the

5-07-2006

names
of the 5
abnormalities
you see.

2.2 ml
10 million/ml
none
25%
30%

20%

+++

Normozoospermia

When all the spermatozoal parameters are normal

together with normal seminal plasma ,WBCs and
there is no agglutination.

Oligozoospermia

When sperm concentration is < 20 million/ml.

Asthenozoospermia

Fewer than 50% spermatozoa with forward

progression(categories (a) and (b) or fewer than 25%
spermatozoa with category (a) movement.

Teratozoospermia

Fewer than 30% spermatozoa with normal

morphology.

Oligoasthenoteratozoospermia

Signifies disturbance of all the three variables

(combination of only two prefixes may also be used).

Azoospermia

No spermatozoa in the ejaculate.

Aspermia

No ejaculate.

Leukocytospermia

more than 1 million white blood cells per ml of semen

Normal values
Volume

2.0 ml or more

pH

7.2-7.8

Sperm concentration

20x106 spermatozoa/ml or more

Total sperm count

40x106 spermatozoa or more

Motility

50% or more with forward progression or

25% or more with rapid progression
within 60 min after collection

Morphology

30% or more with normal morphologyb

Vitality

75% or more live

White blood cells

Fewer than 1x106/ml

 sensitivity of 89%, poor specificity

repeat semen samples provides
greater specificity.
At least two samples, preferably
taken at least two or three weeks
apart, should be analyzed.

 What is the advise you would give

regarding obtaining a semen sample
for analysis

 This test is conducted to check for male factor

subfertility.
Specimen should be produced by masturbation.
Abstinence from intercourse for 3 days.
Condoms should not be used for collection as they contain
spermicide.
Coitus interruptus is not recommended as the first part of
the ejaculate contains the highest concentration of sperm.
Wide mouthed sterile plastic container will be provided.
Sample should be delivered to the lab within 30 min. of
collection.

1.
2.

Identify
List 3 prerequisites in using these instruments

3.

Give 3 indications for these instruments

Wrigleys Forceps

Keillands Forceps

Simpsons Forceps

Always prior to applying forceps

1. Abd examination Head engaged?
2. Confirm that the cervix is fully
dilated
3. Empty the bladder
4. Check station of the presenting
part
5. Position of the foetal skull
Position of the saggital suture &
posterior fontanelle

Prerequisites for applying forceps

Valid indication must be present

Suitable presentation- vertex,face, aftercoming head of breech.

Rule out cephalopelvic dispropotion.

Engaged Presenting part. Position of the fetal head should be known.

Cervix should be fully dilated.

Bladder emptied- preferably by catherisation.

Ruptured membranes.

Abdominally head should not be palpable. If more than 1/5th palpable

abandon vaginal delivery.

Indications for forceps delivery

Delay in progression of second stage of labour

Maternal exhaustion
Medical problems which require avoidance of
excessive maternal effort
Fetal distress in the second stage
Delivery of the after coming head of a breech
presentation

1.

Name the required instruments in order of use when obtaining a

pap smear
2. What is the fixative and the stain used
B

1.

F - Cuscos bivalve self retaining vaginal

speculum
G - Ayres wooden spatula
B - Cytobrush/ Endocervical brush
A - Glass slides

2.

Fixative 95% Alcohol

Stain- Papanicolaou stain
(The glass slide is fixed in 95% alcohol for 30
minutes and air dried before sending to the
histology lab)

1. Name 5 instruments in an episiotomy

set.
2. List 3 complications of an episiotomy
3. What are the advise given to mother
after repairing an episiotomy

Sterile towels (Two)

Sterile sanitary towel

Dressing Scissors

Artery Forceps

Needle Holder

Toothed Catch Forceps

Round body needle

Cutting needle

Complications of episiotomy
Immediate-

Extension of the incision

- Early

Vulval haematoma
Infection
Wound dehiscence
Remote

Dyspareunia

Advise to mother following

episiotomy
Keep the area dry and clean.
Do not use antiseptics, soap is
sufficient.
Can wear a sanitary pad to keep area
dry.

What instruments are used in

the following procedures in
order of use
1. Dilatation & Curettage
2. Repair of a cervical tear

1. D&C :

Performed under GA

Placed in lithotomy position

Local antiseptic cleaning & draping

Sims double bladed posterior vaginal speculum is introduced

Anterior lip of cervix held by vulsellum

Olive pointed malleable graduated metallic uterine sound to confirm position &
length of cavity

Cervical canal dilated with Hegars graduated dilators

Uterine curette sharp end for benign lesions and blunt end used for suspected
malignant lesions

Curetted material preserved in 10% formal saline and sent to histology lab with a
short clinical history.

Post procedure care:

Give paracetamol 500 mg by mouth as needed.
Oxytocin 10 U given foll. ERPC
Offer other health services, if possible, including tetanus
prophylaxis, counselling or a family planning method.
Advise the woman to watch for symptoms and signs requiring
immediate attention:
- prolonged cramping (more than a few days);
- prolonged bleeding (more than 2 weeks);
- bleeding more than normal menstrual bleeding;
- severe or increased pain;
- fever, chills or malaise;
- fainting.

Repair of a cervical tear

Anaesthesia is not required for most cervical tears. For
tears that are high and extensive, give pethidine IM
Good light source and patient is placed in lithotomy position.
Sims speculum is introduced
Gently grasp the cervix with Green armytage forceps. Apply
the forceps on both sides of the tear and gently pull in
various directions to see the entire cervix. There may be
several tears.
Close the cervical tears with continuous chromic catgut (or
polyglycolic) suture starting at the apex (upper edge of
tear), which is often the source of bleeding.

 What are the instruments found in a

delivery set.

Sterile sanitary towels

Gullipot

Artery forceps

Straight scissors
Curved mayos scissors

Kidney tray

CTG
What are the parameters that should
be observed in a CTG
Types of CTGs
If foetus is distresed what features
would you expect

Parameters observed in a
CTG

FHR
Any decelerations in HR
Basal heart rate variation
Frequency of uterine contractions
Strength of uterine contractions

Types of CTGs

Features when foetus is

distressed
Decelerations in FHR

Basal body temperature

chart (BBTC)

1.

What is the day of ovulation

2.

What advise you give on using this

3.

On which day according to the chart would you do the

following

a.
b.
c.
d.
e.

Post Coital Test

Progesterone levels to detect ovulation
Endometrial biopsy
HSG
IUI

0.5-1 0F (0.2-0.5 0C)

Ovulation

2 days

1. Day 14 of the cycle.

2. There is a biphasic pattern of variation in ovulatory cycle.
Begin recording temp. on the first day of the period- day 1 on
the chart.
Measure the oral temp. using a clinical thermometer.
Mark the date in the column and shade the area on the day of
menses.
Take the oral temp daily on waking before getting out of bed.
( do not wash mouth)
Days when intercourse takes place should be noted with an
arrow.

a. Post Coital Test- day 12-13 in a regular

28 day cycle.
b. Progesterone levels to detect ovulation
Day 21 in a 28 day cycle.
c. Endometrial biopsy- Day 21-23 in a 28
day cycle.
d. HSG- First 10 days of the cycle.
e. IUI- washed sperms are placed in the
uterine cavity at the time of ovulation.
Ovulation detected by follicular growth
monitoring by USS.

1.
2.

Identify
Name which one you would use in the following
procedures
To insert an IUCD
In vaginal hysterectomy
In D&C
In obtaining a pap smear
Repair of a cervical tear

Cuscos bivalve self retaining vaginal

speculum
a) Inserting an IUCD
b) Obtaining a pap smear

Sims double bladed posterior vaginal

speculum
a) Vaginal hysterectomy
b) Dilatation and curettage
c) Repair of a cervical tear

1.
2.

What are the instruments needed for the

insertion of an IUCD
Give 3 possible complications

5
4

6
7

Complications
Inter-menstrual bleeding
Pelvic inflammatory disease
Expulsion (1st 3 months)
Perforation

1. Identify
2. List an indication and a
contraindication

Name of instrument Ring pessary

Indications for use of vaginal pessary
a) Prolapse of uterus
b) urinary incontinence
c) cystocele
d) rectocele
Contraindications
a) Active infections of the pelvis or vagina, such as
vaginitis
b) Pelvic inflammatory disease
c) Patients who are noncompliant or unlikely to
follow up
d) Allergy to silicone or latex

Foetal movement chart

1. How to advise mother to maintain a
Foetal movement chart
2. When do you call it abnormal
3. List 3 causes for reduced FM
4. List 3 non invasive tests to assess
foetal well being

Test sensitive for fetal well-being after 28 weeks

Physiology of normal third trimester fetal movement

Fetus spends 10% of its time making gross movements

Active fetal periods last 40 minutes
Inactive fetal periods last 20 minutes (<75 minutes)

Fetal activity peaks with maternal Hypoglycaemia

Usually occurs between 9 pm and 1 am
Activity not increased after meals or glucose load

Advise to mother:

Patient self monitors kick counts daily at home

Count performed at same time every day
Lie on left side in comfortable location
Count fetal movements to a count of 10-12 in 12 hours
If perceived movements are <10/12hrs seek medical
advise

Causes of reduced foetal movements:

Normal sleep phase
Physiological
Reduced maternal perception
Sedative drugs given to mother
Polyhydramnion/oligo
Intrauterine asphyxia
Non-invasive tests to assess foetal well being:
CTG
USS- foetal growth & Liquor., biophysical profile,
Umbilical artery Doppler

USS abd given

(H.Mole or missed abortion)
A) What is the condition
B) What is the diagnosis
C) Give 2 causes

Risk factors
1.
2.

History of previous GTD

Age - Lowest risk Age 25 29 years
6 times higher Age less than 15 yrs
4 times higher - Age 40- 45 yrs
400 times higher over 50 yrs

Maternal DNA
lost from
ovum
23x
Duplicati
on of
haploid
46xx sperm

Proliferation
of
monospermic
androgenetic
complete
HM

Maternal DNA
lost from
ovum
23x

46xy

Two paternal
genetic
contributions

Proliferation
of dispermic
androgenetic
complete
HM

23x

69xxx

Maternal and
two
paternal
genetic
contribution
69xxy

Proliferation
of triploid
partial HM

Absence of a foetus (In complete mole)

Presentation

Snow Storm appearance

1. Vaginal bleeding
2. Passage of vesicular
grape like structures per
vaginum
3. Hyperemesis
4. Early onset PIH
Examination findings
1. Anaemia
2. F>D
Investigations
1. USS abd.
2. S. hCG
3. CXR
Management
1. Evacuation
2. Follow up (2 yrs)- hCG
assays
3. Contraception

Missed abortion